In a case involving falling drywall, a sleeping woman and multiple alleged injuries, changes in a claimant’s story, unexplained delays and other inconsistencies and gaps in several data points raised red flags for MKC’s nurse reviewer.
The event and injury
The claimant a woman reported that a ceiling fell on her while she was asleep, late January 2019. She stated the drywall ceiling struck her left shoulder and the left side of her face. As a result of the incident, she reported multiple subjective complaints to her neck, left shoulder, left elbow and face.
Mechanism of Injury (MOI)
As in most injury claims, the MOI is a deal breaker. In this case, the MOI started out pretty straight-forward, with drywall ceiling falling on the claimant’s face while she was asleep. However, the nurse reviewer noted that as the timeline moved forward, the claimant reported a) that a roof fell on her and b) that she fell off a roof.
Comparison of Pre and Post Date of Loss Records
No pre Date of Loss records were submitted for review.
The nurse review of the medical records noted several data points that were out of alignment with the claim:
- There was a delay in the claimant’s ongoing care. Specifically, the claimant did not return for treatment until one month after the Date of Loss, at which time the reported MOI changed as well as her subjective complaints. When questioned why she delayed treatment for a month, she claimed she lost her appointment card.
- The claimant presented conflicting, inflated pain complaints. While she reported 10/10 pain, the physician objectively stated she was in no distress.
- A delay in following the treatment plan was noted when diagnostics were ordered. The claimant delayed obtaining the recommended imaging studies for two months, raising questions about the veracity of the claimant’s subjective complaints for which the diagnostics were recommended.
Finally, the claimant reported initially that she was employed as a babysitter. However, later in the timeline, the nurse reviewer discovered that the claimant stated working full time in an undisclosed position for a construction company. Despite the possible heavy manual labor which could be required with a construction job, the claimant and the physicians never related job duties to her subjective pain.
The Legal Nurse Consultant review established several key inconsistencies. The nurse’s report noted that the claimant changed the MOI details, possibly in an attempt to explain the expanding subjective complaints. Moreover, the claimant’s gap in treatment of one month not only allowed sufficient time for an intervening injury, but provided a basis in which the adjuster could argue that any treatment after the initial emergency department visit was not related. Finally, the nurse review uncovered inflated subjective pain complaints and inconsistent data as well as a delay in following the recommended treatment plan.